WI0500412_GEO THERMAL_20110808

Permit Number
Program Category
Ground Water
Permit Type
WI0500412 /
•!
Central Files: APS_ SWP_
08/08/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
George & Karen Mertz SFR
Location Address
1221 Poplar Forest Ln
Pittsboro
Owner
Owner.Name
George
Dates/Events
NC
M
27312
Mertz
Orig Issue
08/08/11
App Received Draft Initiated
08/02/11
Re g ulated Activities
Heat Pump Injection
Outfall 1~Ji 1
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
Glen A. Darch
13109 Bold Run Hill Rd
Wake Forest NC
Major/Minor
Minor
Region
Raleigh
County
Chatham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
George M. Mertz
1221 Poplar Forest Ln
Pittsboro NC
Public Notice Issue
08/08/11
Effective
08/08/11
27587
27312
Expiration
Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
George M. Menz
Karen A. Mertz
1221 Poplar Forest Lane
Pinsboro, NC 27312
Ef"A .--.1/~~
CD--EN ..... R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
8/9 /2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500412
1221 Poplar Forest Lane, Pittsboro, NC 27312
Dear Mr. & Mrs. Mertz:
Dee Freeman
Secretary
On 8/2/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onlv
geothermal injection well system for the operation of a ground-source heat pump located .at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .02ll(u)(2). Additionally, you should contact the Chatham County Health
Departinent as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Roeers(a),ncdenr.tt ov if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Files -Permit No. WI0500412
Chatham County Health Dept.
Glen A Darch Well Drilling, LLC (Glen Darch)
Bowman Mechanical Services, .Inc (Steve Bowman)
AQUIFER PROTECTION SECTION
1636 Mail Service Center. Raieigh . North Carolina 27699-1636
Location: 2728 Capital Boulevard , Raleigh, North Carolina 27604
Sincerely,
fo,~b,a~ & -~
Supervisor
Phone : [phone] \ FAX 1: 919-715-0588: FAX 2: 919-715-6048 \ Customer Service : 1-877-623-6748
Internet: www.ncwaterq ualitv.ora
As Equal Opportunity i Afiinnauve Action Employer
None r1 1" · ortbLaro11na
/\Jaturally
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM
TYPE SOW WELL(S)
In Accordance With the Provisions ofNCAC Title 15A 02C.0200
Print or type the required information and mail to address on the back page.
DATE: 7-I b 20_1_1 u.5I-OSC:0 t-(i ~
Well Type Co,ifirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loo p)?
Yes X Continue completing this form.
No ___ Do Not complete this form. Complete other UIC application forms for installing
either a 5A 7 well ( open-loop well injecting potable water into the aquifer) or a SQM well ( closed-
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): (;j.tSo '¼t .. (Y) , (YJ $?_...~
k -AL&v -e . rnE:rc .. :r __ ~
(1) MailingAddress: /~f ft::,pL.p-g__ r°-C)fl...J~T LPr--.k-
City: P1 T'rs es->tt..o Statef\.X?_Zip Code:cn-3 ,a CountyQft·47:"f.1 Pc:\
Home/Office Tele No.:°\ I '1-S'fc()...-QS-'f ~ Cell No.:
Email Address: ________ ~W_e_b_si_te_: ____________ _
(2) Physical Address of Well Site (if different than above): _5;...,A'(l.......,_---'-'f;.......,..,, _________ _
City: _________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: -----------~C~e=ll~N~o=·=~----------
B. AUTHORIZED AGENT OF OWNE~ IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: ____________________________ _
ContactPerson~: ______________ E=MAIL===A=d=dr=e=ss~=-----------
Address: --------------------------------
City: _________ State: __ Zip Code: ______ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: _____________ ___,ucAQ,l.w~Jr:~C ~/VEO / DENR / DWQ
R PROTt=r.noN SECTION
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) AUG O 2 2011 Page 1
C. WELL DRILLER INFORMATION
G-ten .9 1 P) Wed A // L ZC
Company Name:
Well Driller Contractor's Name: [r- /e n /9 d (--',-G4'
NC Contractor Certification No.: 3900 r9
Contact Person:
Address:
'3/c`J gold dPvn I' // /
City: Wake 'fves1 Zip Code: Z 7587 County:
Office TeleNo.: L J /9Jl33-6' - 363, Cell No.: On) 9ZZ— 993/ fax [phone]
EMAIL Address:
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
ptyrnkn eC a,ic4-1
EMAIL Address: nrn ec 4 I Icciab 1 el6o. '. IR/
Company Name:
Contact Person:
Address: hi c
%ecA C
City: C-r/►?r Zip Code: 7- 73' Z.') County: (rfa
�
Office Tele No.: 19 7 Z' �73-1
i Io.: Cc/ /91 7 79 - 919
E. STATUS OF APPLICANT
Private: X Federal: Commercial:
State: Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: e /! / / / Number of borings:
Approximate depth of each boring (feet): Z SCE
(2) Type of tubing to be used (copper, PVC, etc):
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: _galvanized steel black steel plastic other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends to above ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type; Neat Cement Bentonite Other (specify)
(b) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from _CIC- to 2- 5 (feet)
If well has casing, indicate grout depth: from to (feet)
GP[U1[J[C 5QW Notification of Intent Form (Revised 8/2008)
Page 2

H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
.I. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that l have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on •my inquiry of those individuals
immediately responsible for obtaining said information, l believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibility of lines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the appfoved specifications and conditions of the Permit."
Owner/Xpplicant
'-Cam YZ'1 rY ! tz i
Print or Type Full Name and title
p_ j1L
Signature of I roperty Owner/Applicant
-1-
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-11C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED IDENRIDWO
AQUiFF4t'PgowcrinN AFC,TION
AUG02201f
GP[IRJTC 5QW Notification of Intent Form (Revised 8/2008) Page 3

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